Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Walter B Crook Nursing Facility during CMS and state inspections, most recent first.
A resident with MS and intact cognition developed a sacral pressure injury that was not accurately identified, documented, or treated when first found. Weekly skin audits noted no new skin issues, and a nurse received ER wound care orders but did not enter or carry them out, leaving the wound undocumented in the EMR and later re-identified as a stage III pressure ulcer.
A resident’s quarterly MDS was coded incorrectly in Section N to show insulin injections when the MAR showed no insulin order and no insulin administration. The MDS Coordinator confirmed the error and stated the resident only received a flu shot, while the resident’s record also showed dementia and an inability to complete the BIMS interview.
Failure to develop and follow comprehensive care plans affected four residents. Two residents had care plans for psychotropic medication monitoring, but the MAR showed no documentation that side effects were monitored every shift, and an LPN confirmed the monitoring was not being done. Two other residents had no nail care plans despite observations of long, jagged nails with brown substance underneath; one resident stated a desire to have her nails cut shorter, and the DON and an LPN confirmed the missing nail care plans.
Failure to provide proper fingernail care for two residents. One resident had long, jagged fingernails with brown substance underneath and said she wanted them cut shorter; staff confirmed nail care was part of hygiene and could be provided by nurses or CNAs unless the resident was diabetic. Another resident was observed with long, dirty nails and a contracted hand, and an RN and DON confirmed staff were expected to keep fingernails trimmed and clean. Both residents had cerebral infarction and severe cognitive impairment.
Failure to Provide Bowel and Bladder Retraining: A resident with MS and epilepsy, who was cognitively intact and had incontinent episodes, was identified through bowel/bladder screenings as a candidate for retraining and scheduled toileting. However, the facility did not have a B/B toileting program, there was no documented RN follow-up after screenings, and staff confirmed the resident was not on a toileting program despite care plan language indicating individualized toileting support.
Failure to monitor side effects of psychotropic medications for two residents. One resident received quetiapine for Major Depressive Disorder and another received Seroquel for Major Depressive Disorder, but the MAR showed no indication that side effects were being monitored. An LPN confirmed the monitoring was not being done, and another LPN stated the monitoring did not carry over after a charting system change. One resident was cognitively intact, and the other had dementia with behavioral disturbance.
An LPN failed to use EBP while administering PEG medications to a resident with a feeding tube. The facility’s EBP policy required gown use during high-contact care involving devices such as feeding tubes, and the LPN later confirmed EBP should have been used but was forgotten. The DON stated EBP was expected for care involving tubes or wounds, and the resident had diagnoses including hemiplegia and hemiparesis with a BIMS score of 0.
Failure to Identify and Treat Resident Pressure Injury
Penalty
Summary
The facility failed to identify, accurately assess, document, and implement treatment for a pressure injury for one resident, resulting in an avoidable full-thickness tissue loss wound that was not treated after identification for ten days because the physician order was not implemented. The resident was admitted with multiple sclerosis and was cognitively intact with a BIMS score of 14. Review of the facility wound care policy showed expectations for proactive wound prevention, prompt identification and treatment, advanced wound care, and minimizing infection risks, but the documented care did not reflect those requirements. Record review showed the resident’s sacrum and bilateral buttocks were clear on hospital discharge, but a skin/wound note later documented a stage III pressure ulcer on the sacral area with slough and eschar. Weekly skin audits documented no new skin issues, including one audit that noted no new skin issues per CNA. The April TAR showed a coccyx ointment order was initialed as completed on several days without documentation of a change in skin condition. Staff later stated a night shift CNA found an open area to the sacrum, completed a body audit form, and notified the nurse, who received ER treatment orders but did not carry them out or enter them into the EMR. The note was left in a binder at the nurse’s station, and there was no EMR documentation or completed orders until the wound was later re-identified as a stage III pressure ulcer.
Incorrect MDS Coding for Medication Administration
Penalty
Summary
The facility failed to accurately code a quarterly MDS assessment for one resident. For Resident #6, the quarterly MDS with an ARD of 10/14/25 was coded in Section N, N0350 as having received insulin injections for one day during the last seven days, but the MAR for 10/1/2025 through 10/31/2025 showed no insulin order and no insulin injections administered. The resident’s immunization record showed an influenza vaccination on 10/8/25, and the MDS Coordinator confirmed during interview that the resident did not receive insulin injections and that the MDS was coded incorrectly. The resident’s record also showed diagnoses of unspecified dementia with other behavioral disturbance, and the BIMS score of 99 indicated the resident was unable to complete the interview.
Failure to Develop and Follow Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans that included measurable objectives and timetables for residents’ needs, and failed to implement existing care plans for psychotropic medication monitoring. For Resident #2, the care plan identified risk for adverse effects related to psychotropic medications for major depressive disorder and anxiety disorder and directed staff to monitor for side effects and effectiveness every shift, but the November 2025 MAR contained no documentation of side effect monitoring. For Resident #7, the care plan identified antidepressant medication use for major depressive disorder and directed staff to monitor and document side effects and effectiveness every shift, but the November 2025 MAR also contained no documentation of side effect monitoring. An LPN confirmed the monitoring was not being done, and the Care Plan Coordinator confirmed the care plans for both residents were not followed. Resident #2 was admitted with major depressive disorder and had a BIMS score of 15, while Resident #7 was admitted with unspecified dementia with behavioral disturbance and was unable to complete the BIMS interview. The facility also failed to develop care plans for nail care for Resident #8 and Resident #46. Resident #8, who was admitted with cerebral infarction and had a BIMS score of 7, was observed on two occasions with approximately 3/4-inch long, jagged fingernails with brown substance underneath, and stated she wanted her nails cut shorter. The DON confirmed no nail care plan had been developed. Resident #46, who was admitted with cerebral infarction and had a BIMS score of 6 with severely impaired cognitive skills for daily decision making, was observed on two occasions lying in bed with long nails, including approximately 1/4-inch nails on the left hand and 1/2-inch nails on the right hand with brown substance underneath; the right hand was contracted and clenched in a fist. An LPN confirmed no nail care plan had been developed for Resident #46.
Failure to Provide Proper Fingernail Care
Penalty
Summary
The facility failed to provide proper nail care for two sampled residents. Facility policy stated that residents unable to perform activities of daily living independently were to receive services necessary to maintain grooming and personal hygiene, and that fingernail and toenail care was intended to clean the nail bed, keep nails trimmed, and prevent infections. During observation and interview, one resident was found with fingernails approximately 3/4 inch long with jagged edges and brown substance underneath, and the resident stated a desire to have the nails cut shorter. A CNA confirmed the nails were long and jagged, and the treatment nurse confirmed the condition of the nails and stated that nail care could be provided by nurses and CNAs unless the resident was diabetic. The resident had a diagnosis of cerebral infarction and a BIMS score of 7, indicating severe impairment. A second resident was observed lying in bed with long fingernails on both hands, with brown substance underneath, and the right hand was contracted in a clenched fist. An RN confirmed the nails were long and dirty and opened the resident's hand to show all fingernails were long with brown substance underneath; no broken skin was observed. The RN and DON stated that staff were expected to keep residents' fingernails trimmed and clean, and that long or dirty nails could cause a break in the skin and lead to infection. This resident also had a diagnosis of cerebral infarction and a BIMS score of 6, with severely impaired cognitive skills for daily decision making.
Failure to Provide Bowel and Bladder Retraining
Penalty
Summary
The facility failed to provide bowel and bladder training services to reduce incontinence for one resident. Record review showed the resident had bowel/bladder screenings that identified the resident as a good candidate for retraining and later as a candidate for scheduled toileting. The resident’s care plan stated that staff were helping the resident retrain bladder and bowel control so the resident could stay dry and comfortable as much as possible, with interventions including adjusting the schedule based on bladder pattern or resident feedback, interdisciplinary review during quarterly and significant change assessments, and weekly nurse review for progress or modification needs. During interviews, the Administrator, DON, and RN care plan coordinator stated the facility did not currently have a bowel/bladder toileting program and that after screenings were completed, an RN reviewed the screening and made a decision or recommendation. They also confirmed the resident had incontinent episodes and was not on a toileting program because the facility did not have one. The nurses stated there was no documentation following each bowel/bladder screening by an RN assessing the need for the program, and the DON stated staff did remind the resident to toilet every few hours but there was no documentation of that. The resident had diagnoses including Multiple Sclerosis and Epilepsy, and the MDS showed a BIMS score of 15, indicating the resident was cognitively intact.
Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
The facility failed to monitor for side effects of psychotropic medications for two residents reviewed for unnecessary medications. Facility policy titled Antipsychotic Medication Use stated that nursing staff shall monitor for and report side effects and adverse consequences of antipsychotic medications to the attending physician. Record review showed that one resident had an order for Quetiapine Fumarate 25 mg by mouth three times a day related to Major Depressive Disorder, and another resident had an order for Seroquel 50 mg by mouth in the evening related to Major Depressive Disorder. For both residents, there was no indication on the MAR that side effects were being monitored. An LPN stated that side effects were supposed to be monitored for all residents taking psychotropic medication and confirmed they were not being monitored for these two residents. Another LPN stated that when the facility changed charting systems in July 2024, side effect monitoring did not carry over into the new medical record system. One resident was cognitively intact with a BIMS score of 15, and the other had a diagnosis of unspecified dementia with behavioral disturbance and was unable to complete the BIMS interview.
Failure to Use Enhanced Barrier Precautions During PEG Medication Administration
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff failed to maintain infection control practices during care for Resident #13. The facility policy for Enhanced Barrier Precautions (EBP), effective 4/1/24, stated that EBP is used during high-contact resident care activities, including device care such as urinary catheters, feeding tubes, and central lines. During observation of medication administration on 11/12/2025 at 9:08 AM, an LPN administered PEG medications to Resident #13 without using EBP and did not wear a gown. During interview later that morning, the LPN confirmed that EBP should have been used for medication administration for residents with PEG tubes and stated she forgot to put the gown on before giving the medications. The DON stated that EBP should be used with any tubes or wounds to prevent possible cross contamination and that staff were expected to follow EBP with all care provided for residents with a tube or wound. Record review showed Resident #13 was admitted with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease, and the quarterly MDS indicated a BIMS score of 0, meaning the resident was rarely or never understood.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ruleville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ruleville Community Care Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Cleveland Community Care Center | 8.8 mi | ★★★★★ | 9 | 0 |
| Bolivar Medical Center Ltc | 9.4 mi | ★★★★★ | 0 | 0 |
| Delta Rehabilitation And Healthcare Center | 9.4 mi | ★★★★★ | 0 | 0 |
| Diversicare Of Shelby | 19.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.